Apparatus and method for pericardial access

ABSTRACT

Implementations described and claimed herein provide controlled access into the intra-pericardial space. In one implementation, a medical device comprises an outer sheath, an inner sheath, and a nose shaft. The outer sheath comprises a proximal end, a distal end, and a lumen extending between the proximal end and the distal end. The inner sheath extends through the lumen of the outer sheath and comprises a distal portion adapted to pierce the pericardial sac. The nose shaft is adapted to displace relative to a distal edge of the distal portion of the inner sheath. Displacing the distal portion of the inner sheath relative to the outer sheath until the nose shaft displaces relative to the distal edge provides controlled penetration into the intra-pericardial space.

CROSS REFERENCE TO RELATED APPLICATIONS

The presently disclosed technology relates to medical apparatuses andmethods. More specifically, the presently disclosed technology relatesto an apparatus and a method for accessing an intra-pericardial space.

FIELD OF THE INVENTION

The presently disclosed technology relates to medical apparatuses andmethods. More specifically, the presently disclosed technology relatesto an apparatus and a method for accessing an intra-pericardial space.

BACKGROUND OF THE INVENTION

The heart is enveloped within a tissue membrane structure known as thepericardium or pericardial sac. The pericardium consists of two layers,the fibrous pericardium and the parietal pericardium, which is a serouslining adjacent to the fibrous pericardium. In some instances referenceis made to a third visceral pericardial layer, the epicardium, which isthe layer on the surface of the myocardium. Between the pericardial sacand the surface of the heart is an intra-pericardial space.Approximately 15 to 35 milliliters of serous fluid fills theintra-pericardial space, providing lubrication and protection for theheart.

For patients in need of cardiac rhythm treatment (CRT), a minimallyinvasive pericardial approach to placing a stimulating lead (e.g., achronic cardiac pacing lead) has recently been used as an alternative totransvenous and invasive surgery methods. In the pericardial approach,doctors access the intra-pericardial space to place a stimulating leadon the epicardial surface. Needle and needle-like tools are generallyused to gain access to the intra-pericardial space.

For example, some of these tools employ a distal suction cup tostabilize the pericardial sac while a needle punctures the pericardialsac and enters the intra-pericardial space. However, there is difficultymaintaining a vacuum to stabilize the pericardial sac and the diameterof a percutaneous port in these tools must be sufficiently large (e.g.,18 French diameter or larger). Many other tools access theintra-pericardial space by grabbing and stabilizing the pericardial sacwhile a needle is advanced into the pericardial space. Such tools maygrab the pericardial sac, for example, using clips or pinchers. However,such tools often encounter challenges to accessing the intra-pericardialspace when obstructions to the pericardial sac are present. For example,the pericardial sac is covered in a layer of fat, which varies inthickness from patient to patient.

In another approach that is unaffected by the layers of fat surroundingthe pericardial sac, doctors gain percutaneous access into theintra-pericardial space using a sub-xiphoid puncture technique employingan epidural Touhy needle, for example, a 17-gauge Touhy needle.Visualization techniques, such as fluoroscopy, MRI, echocardiography, orendoscopy are generally used to guide the needle to an implantationlocation within the intra-pericardial space and to guide positioning ofthe stimulating lead. Contrast media may be used during puncture todetermine if the needle has passed through the pericardial sac and iscorrectly positioned in the intra-pericardial space. However, suchtechniques pose the risks of the needle puncturing the myocardium,entering the heart chambers, and causing excessive bleeding.

Specifically, for patients with a relatively normal pericardial sac,gaining access into the intra-pericardial space using a needle isdifficult. This difficulty arises because: the pericardial sac isgenerally a thin tough connective tissue with little stretchability; thepericardial sac is slippery on, and slides over the heart wall; and thevirtual space available for puncture provides little puncture room forpressing the needle into the pericardial sac. The term “virtual space”refers to the potential space between the two extreme limits of theepicardial surface and the pericardial sac. The challenges of accessingthe intra-pericardial space can easily result in the heart wall beingpunctured, increasing the risk for tamponade (i.e., compression of theheart by an accumulation of fluid or blood in the pericardial sac).

Accordingly, there is a need in the art for a method and apparatus thatwill facilitate accessing the intra-pericardial space while reducing therisk of puncturing the heart wall.

BRIEF SUMMARY OF THE INVENTION

Implementations described and claimed herein address the foregoingproblems by providing controlled access into the intra-pericardialspace. In one implementation, a medical device comprises an outersheath, an inner sheath, and a nose shaft. The outer sheath comprises aproximal end, a distal end, and a lumen extending between the proximalend and the distal end. The inner sheath extends through the lumen ofthe outer sheath and comprises a distal portion adapted to pierce thepericardial sac. The nose shaft is adapted to displace relative to adistal edge of the distal portion of the inner sheath. Displacing thedistal portion of the inner sheath relative to the outer sheath untilthe nose shaft displaces relative to the distal edge provides controlledpenetration into the intra-pericardial space.

Another implementation provides a method for controlled access into theintra-pericardial space. The method comprises positioning a distalportion of an inner sheath in close proximity to a pericardial sac. Theinner sheath is located in an outer sheath. The pericardial sac isengaged with a hook on the distal portion of the inner sheath. The innersheath is displaced relative to the outer sheath until an indicatorlocated on a proximal portion of a nose shaft displaces relative to aproximal end of the outer sheath. The displacement of the indicatoridentifies when a distal tip of the nose shaft is positioned in theintra-pericardial space.

Other implementations are also described and recited herein. Further,while multiple implementations are disclosed, still otherimplementations of the presently disclosed technology will becomeapparent to those skilled in the art from the following detaileddescription, which shows and describes illustrative implementations ofthe presently disclosed technology. As will be realized, the presentlydisclosed technology is capable of modifications in various aspects, allwithout departing from the spirit and scope of the presently disclosedtechnology. Accordingly, the drawings and detailed description are to beregarded as illustrative in nature and not limiting.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a schematic representation of an implementation of adevice being employed for controlled access into intra-pericardialspace.

FIG. 2 illustrates a longitudinal sectional side view of animplementation of the device positioned in close proximity to apericardial sac.

FIG. 3 illustrates the same view as FIG. 2, except the device hasengaged the pericardial sac.

FIG. 4 illustrates the same view as FIG. 2, except the distal tip of thenose shaft is positioned in the intra-pericardial space.

FIG. 5 illustrates the same view as FIG. 2, except the guidewire hasbeen deployed.

FIG. 6 illustrates a side elevation view of a patient with the distalend of the device inserted into the patient via a sub-xiphoid access.

FIG. 7 illustrates a side view of an implementation of the device atrest.

FIG. 8 illustrates the same view as FIG. 7, except the outer sheath hasbeen displaced distally.

FIG. 9 illustrates the same view as FIG. 7, except the nose shaft hasbeen displaced proximally.

FIG. 10 illustrates a side view of a portion of an implementation of theinner sheath and distal tip of the nose shaft.

FIG. 11 illustrates a side view of a portion of an implementation of theinner sheath and outer sheath.

FIG. 12 illustrates a side view of a portion of an implementation of thedistal portion of the inner sheath and of the nose shaft.

FIG. 13 illustrates a side view of an implementation of the deviceinserted through the body tissue and has engaged the pericardium.

FIG. 14 illustrates the same view as FIG. 13, except the distal tip ofthe nose shaft has pierced the pericardium and the guidewire has beendeployed.

DETAILED DESCRIPTION

Aspects of the presently disclosed technology involve a device andmethod for controlled access into an intra-pericardial space. In oneimplementation, the device includes an outer sheath and an inner sheathextending through a lumen of the outer sheath. The inner sheathcomprises a distal portion adapted to pierce the pericardial sac. Thedevice further includes a nose shaft adapted to displace relative to adistal edge of the distal portion of the inner sheath.

The device may be inserted into a patient, for example, via asub-xiphoid access, a transthoracic keyhole access, or other minimallyinvasive access. After insertion, the distal portion of the inner sheathis positioned against a surface of the patient's pericardial sac suchthat a hook on the distal portion of the inner sheath engages thepericardial sac. The inner sheath is displaced relative to the outersheath until an indicator located on a proximal portion of the noseshaft displaces distally relative to a proximal end of the middlesheath. The displacement of the indicator identifies when a distal tipof the nose shaft is positioned in the intra-pericardial space, therebyproviding controlled access to the intra-pericardial space.

The device and method provide a precise, controlled puncture of thepericardial sac with little risk of puncturing the heart surface. Thus,the device and method are advantageous because they are unaffected byobstructions located on the pericardial sac (e.g., fat), eliminatetenting of the pericardium, eliminate the need for a needle to puncturethe pericardial sac, increase the predictability of procedures involvingaccess to the intra-pericardial space (e.g., implant procedures), reduceimplant time and fluoroscopy time, and allow the pericardial sac to bepunctured in all four chamber zones of the heart.

For a detailed discussion of an implementation of the device and method,reference is made to FIG. 1, which is a schematic representation 100 ofan implementation of a device 102 being employed for controlled accessinto an intra-pericardial space 104. As shown in FIG. 1, theintra-pericardial space 104 is the space between the heart surface 106and the pericardial sac 108. After the device 102 is inserted into apatient, a distal end 110 of the device 102 is positioned in closeproximity to the pericardial sac 108 and a proximal end 112 of thedevice 102 extends from the patient such that an implanter (e.g., adoctor) may control the operation of the device 102. An exampleimplementation of the device 102 inserted into a patient may beunderstood from FIG. 6.

In one implementation, the device 102 includes an outer sheath 114, aninner sheath 116 extending through a lumen of the outer sheath 114, anda nose shaft 118 extending through a lumen of the inner sheath 116. Adistal portion 120 of the inner sheath 116 is adapted to pierce thepericardial sac 108 and advance the distal end 110 of the device 102into the intra-pericardial space 104. Stated differently, the distalportion 120 of the inner sheath 116 is displaced distally relative tothe outer sheath 114 to advance the distal end 110 of the device 102through the pericardial sac 108. Once the distal portion 120 of theinner sheath 116 is positioned in the intra-pericardial space 104, thenose shaft 118 is displaced distally relative to the inner sheath 116.The displacement of the nose shaft 118 notifies the implanter that thedistal end 110 of the device 102 is positioned in the intra-pericardialspace 104 and that no further advancement is needed. This notificationensures an implanter does not continue to advance the distal end 110 ofthe device 102 into the heart surface 106. Additionally, in oneimplementation, the nose shaft 118 distally terminates with a blunt orotherwise atraumatic surface to prevent the distal portion 120 of theinner sheath 116 from piercing the heart surface 106.

An opening 122 exists in a wall of the nose shaft 118 near the distalend 110 of the device 102 and exposes a lumen of the nose shaft 118,through which a guidewire or other medical device may be deployed intothe intra-pericardial space 104 once the distal end 110 of the device102 is positioned in the intra-pericardial space 104. With the guidewireor other medical device in place, the device 102 may be removed andcatheters or introducers with dilators may be advanced over theguidewire into the intra-pericardial space 104 during procedures,including without limitation, implants, surgeries, diagnostics,therapies, reduced patient trauma, and other minimally invasiveprocedures.

As can be understood from FIGS. 2-5, which are longitudinal sectionalside views 200, 300, 400, and 500 of an implementation of the device andmethod, the device 102 is adapted to provide controlled access to theinter-pericardial space 104. As shown in FIG. 2, the distal end 110 ofthe device 102 is positioned in close proximity to the pericardial sac108. The pericardial sac 108 consists of two layers, the fibrouspericardium 202 and the parietal pericardium 204, which is a serouslining adjacent to the fibrous pericardium 202. Often, the fibrouspericardium 202 is covered in a layer of fat 210, which varies inthickness from patient to patient. In some instances reference is madeto the heart surface 106, illustrated in FIG. 2 as the epicardium 206,which is the layer on the surface of the myocardium 208. Between theparietal pericardium 204 and the epicardium 206 is the intra-pericardialspace 104.

In one implementation, the distal portion 120 of the inner sheath 116 islongitudinally displaceable within the lumen of the outer sheath 114. Asdepicted in FIG. 2, a middle sheath 212 that connects to the innersheath at the proximal end is adapted to displace distally, as shown inFIG. 2 by the bolded arrow, causing the distal portion 120 of the innersheath 116 to distally displace longitudinally relative to the outersheath 114. Stated differently, the middle sheath 212 is displaceddistally into a proximal end 214 of the outer sheath 114 causing thedistal portion 120 of the inner sheath 116 to extend from a distal end216 of the outer sheath.

The nose shaft 118 distally terminates with a distal tip 218, which is ablunt surface. In one implementation, the distal tip 218 of the noseshaft 118 is spring loaded so as to remain protruding out of a distaledge 220 of the inner sheath 116 until the distal tip 218 is met withresistance from the fibrous pericardium 202 and/or the fat layer 210.

As depicted in FIG. 3, the device 102 is adapted to longitudinallydisplace the inner sheath 116 until the distal portion 120 of the innersheath 116 engages the pericardial sac 108. In one implementation, thedistal tip 218 of the nose shaft 118 is adapted to proximally displacerelative to the distal edge 220 of the inner sheath 116 when met withresistance from body tissue. For example, when the distal tip 218 is metwith resistance from the fibrous pericardium 202 and/or the fat layer210, the distal tip 218 retracts into the distal portion 120 of theinner sheath 116, as shown in FIG. 3. The displacement of the distal tip218 causes an indicator 302 located on a proximal portion 304 of thenose shaft 118 to displace proximally relative to the proximal end ofthe middle sheath 212 that is connected to the inner sheath 116, asshown in FIG. 3 by the bolded linear arrow. In one implementation, theindicator 302 is a red colored band. However, other colors, designs, andvisuals are contemplated. The indicator 302 notifies the implanter thatthe distal tip 218 of the nose shaft 118 has met resistance from bodytissue, such as the pericardial sac 108, and is thus retracted.

The displacement of the distal tip 218 of the nose shaft 118 into thedistal portion 120 of the inner sheath 116 causes the distal edge 220 ofthe inner sheath 116 to become a leading distal edge or point of thedevice 102. As discussed in detail later in this Detailed Description, ahook 1202 that is located on the distal edge 220 is exposed on thedistal portion 120 by the nose shaft 118 displacing into the innersheath 116, the hook 1202 thereby being positioned and adapted to engagethe pericardial sac 108. In one implementation, the distal portion 120includes helical spiral threads 306 having a cutting surface connectedto the hook 1202, the hook 1202 being an extension of at least onethread. In one implementation, the helical spiral threads 306 and theinner sheath 116 taper down distally. When the indicator 302 notifiesthe implanter that the distal tip 218 of the nose shaft 118 isretracted, the inner sheath 116 is axially rotated by way of the middlesheath 212 causing the inner sheath 116 to longitudinally androtationally displace relative to the outer sheath 114. As a result, thehook 1202 engages and cuts the fat layer 210 and the pericardial sac108, the helical spiral threads on the distal portion 120 feeding thefat layer 210 and the pericardial sac 108 along the inner sheath 116 asthe hook 1202 and distal edge 220 cut through the tissue. In oneimplementation, the inner sheath 116 is axially rotated in a clockwisemotion, as illustrated in FIG. 3 by the bolded arrow. Those skilled inthe art will understand that the piercing of the pericardial sac 108 inthis manner provides precise, controlled access to the intra-pericardialspace 104 and that tenting of the pericardial sac 108 is significantlyreduced.

FIG. 4 illustrates the distal tip 218 of the nose shaft 118 positionedin the intra-pericardial space 104. Once the distal portion 120 of theinner sheath 116 pierces the fat layer 210, the fibrous pericardium 202,and the parietal pericardium 204 and enters the intra-pericardial space104, the distal tip 218 of the nose shaft 118 displaces distallyrelative to the distal edge 220 of the inner sheath 116, as shown by thebold arrow in FIG. 4 positioned near the distal tip 218. In oneimplementation, the distal tip 218 distally springs back into a positionsuch that the distal tip 218 protrudes from the distal edge 220 of theinner sheath 116, as discussed with respect to FIG. 2, before the distaltip 218 was met with resistance from body tissue. The displacement ofthe distal tip 218 causes the indicator 302 to displace distallyrelative to the proximal end of the middle sheath 212 that is connectedto the inner sheath 116, as shown by the bold arrow in FIG. 4 positionedat the proximal end 112 of the device 102. In one implementation, theindicator 302 is retracted distally into the proximal end of the middlesheath 212 that is connected to the inner sheath 116, such that theindicator 302 is not visible, as illustrated in FIG. 4. The displacementof the indicator 302 identifies when the distal tip 218 of the noseshaft 118 is positioned in the intra-pericardial space 104. At thispoint, the implanter stops rotating the inner sheath 116. If the distaltip 218 is placed in close proximity to the heart surface 106, thepulsing heart surface 106 will bump against the distal tip 218 causingthe indicator 302 to appear and disappear, notifying the implanter thatthe distal tip 218 is in close proximity to the heart surface 106.Further, as shown in FIG. 4, the helical spiral threads 306 grip andstabilize the pericardial sac 108, thereby preventing loss of accessinto the pericardial space. Also, the gripping of the pericardial sacvia the threads results in an implementation of the device 102 andmethod lifting the pericardial sac 108 from the heart surface 106,thereby increasing the virtual space if desired. Displacing the innersheath 116 proximally after piercing the pericardial sac 108 lifts thepericardial sac 108, as can be understood from FIG. 4.

As depicted in FIG. 5, a guidewire 502 may be deployed through theopening 122 of the distal tip 218 into the intra-pericardial space 104.The device 102 is adapted to accept the guidewire 502 at the proximalend 112 of the device 102 into the proximal portion 304 of the noseshaft 118. The guidewire 502 is advanced through the lumen of the noseshaft 118 and exits the nose shaft 118 through the opening 122 into theintra-pericardial space 104. Once positioning of the guidewire 502 inthe intra-pericardial space 104 has been confirmed, the inner sheath 116may be axially rotated to disengage the device 102 from the pericardialsac 108. For example, in one implementation, the inner sheath 116 isrotated counterclockwise to disengage the device 102 from thepericardial sac 108. Once the device 102 is disengaged from thepericardial sac 108, the device 102 may be removed from the patient,leaving the guidewire in place for further procedures.

FIG. 6 illustrates a side elevation view 600 of a patient 602 with thedistal end 110 of the device 102 inserted into the patient 602 via asub-xiphoid access 604. However, those of ordinary skill in the art willrecognize the device 102 may be inserted into the patient 602 usingother minimally invasive access, including, but not limited to, atransthoracic keyhole access.

As can be understood from FIGS. 1-5, after insertion, the distal portion120 of the inner sheath 116 is positioned against a surface of thepericardial sac 108 such that the hook 1202 on the distal portion 120 ofthe inner sheath 116 engages the pericardial sac 108 and the nose shaft118 is pushed into the confines of the distal portion 120 and theindicator 302 is caused to appear at the proximal end 304. The innersheath 116 is rotationally displaced relative to the outer sheath 114 byway of the middle sheath 212 until the distal edge 220 cuts through thetissue to free the nose shaft 118 to distally protrude from the distaledge 220 and through the tissue, causing the indicator 302 to displacedistally relative to the proximal end 112 of the middle sheath 212. Thedisplacement of the indicator 302 identifies when the distal tip 218 ofthe nose shaft 118 is positioned in the intra-pericardial space 104. Asa result, controlled access to the intra-pericardial space 104 isprovided, as depicted in FIG. 4, which illustrates such an occurrence.

The intra-pericardial space 104 may then be accessed to allowimplantation of a medical device, such as a stimulating lead. Forexample, as depicted in FIG. 5, the guidewire 502 may be routed throughthe lumen of the nose shaft 118 and into the intra-pericardial space 104to later deposit a pacing or defibrillation lead on the heart surface106. Once the guidewire 502 is routed to the heart surface 106, theinner sheath 116 may be axially rotated to release the pericardial sac108. The device 102 is then withdrawn from the patient 602, leaving theguidewire 502 in place, which can then be used to implant thestimulating lead via the use of catheters and/or introducer sheathstracked into the intra-pericardial space 104 over the guidewire 502.

For a detailed discussion of an implementation of the device 102 andmethod, reference is made to FIG. 7, which is a side view of the device102 at rest. As shown in FIG. 7, in one implementation, the device 102includes the outer sheath 114, the inner sheath 116, and the nose shaft118. The inner sheath 116 includes the distal portion 120, which isadapted to pierce body tissue, such as the pericardial sac 108. In oneimplementation, the device 102 further includes a grip portion 702coupled to the proximal end 214 of the outer sheath 114. The middlesheath 212 is adapted to rotate to cause the inner sheath 116 torotationally and longitudinally displace relative to the outer sheath114. The grip portion 702 provides stability during this motion.

In one implementation, a luer lock valve 704 is connected to theproximal portion 304 of the nose shaft 118 at the proximal end 112 ofthe device 102. Contrast can be injected into the luer lock valve 704 tovisualize during fluoroscopy. The nose shaft 118 extends through a lumendefined by the inner sheath 116, which extends through a lumen definedby the outer sheath 114. Thus, the nose shaft 118, the inner sheath 116,and the outer sheath 114 are concentrically arranged relative to eachother.

As can be understood from FIGS. 8 and 9, which are, respectively, sideviews of the device 102 with the outer sheath 114 displaced distally andwith the nose shaft 118 displaced proximally, the inner sheath 116 islongitudinally displaceable within the lumen of the outer sheath 114,and the nose shaft 118 is longitudinally displaceable within the lumenof the inner sheath 116. Accordingly, as depicted in FIG. 8, the outersheath 114 may be moved distally such that the inner sheath 116 issubstantially located within the outer sheath 114 and a position marker802 (i.e., the position marker 802 associated with the inner sheath 116)is exposed on the middle sheath 212. Stated differently, the positionmaker 802 displaces proximally such that the position maker 802 on themiddle sheath 212 is visible outside the grip portion 702. As depictedin FIG. 9, the inner sheath 116 and nose shaft 118 are displacedproximally within the outer sheath 114 causing the indicator 302 of theproximal portion 304 of the nose shaft 118 to displace proximally. Inother words, the indicator 302 displaces proximally such that theindicator 302 is visible outside the middle sheath 212.

FIGS. 10-12 each illustrate a side view of a portion of animplementation of the distal end 110 of the device 102. As depicted inFIG. 10, the distal end of 110 of the device 102 includes the distal tip218 of the nose shaft 118 and the distal portion 120 of the inner sheath116. The distal portion 120 is adapted to pierce body tissue, such asthe fat layer 210 and the pericardial sac 108. In one implementation,the distal portion 120 includes helical spiral threads 306, and thedistal portion 120 is rotated such that the helical spiral threads cutand advance through the body tissue. The distal portion 120 distallyterminates at the distal edge 220, and the nose shaft 118 distallyterminates with the distal tip 218, which is a blunt surface. The noseshaft 118 is adapted to longitudinally displace relative to the distaledge 220. In one implementation, the distal tip 218 is spring loaded soas to remain protruding out of the distal edge 220 of the distal portion120 until the distal tip 218 is met with resistance from body tissue,such as the pericardial sac 108. The nose shaft 118 further includes theopening 122, which exposes the lumen of the nose shaft 118, throughwhich the guidewire 502 or other medical device may be deployed.

As can be understood from FIG. 11, which illustrates a side view of theinner sheath 116 and outer sheath 114, the inner sheath 116 extendsthrough the lumen of the outer sheath 114. The outer sheath 114 distallyterminates at the distal end 216. In one implementation, the distal end216 tapers distally creating a cutting edge for easier advancement ofthe outer sheath through tissue. The distal portion 120 is adapted todisplace rotationally and longitudinally relative to the distal end 216.Accordingly, as depicted in FIG. 11, the distal portion 120 can beextended from the outer sheath 114 such that the helical spiral threads306 are substantially or even completely located past the distal end216. Additionally, the distal portion 120 can be retracted into theouter sheath 114 such that the helical spiral threads 306 aresubstantially located within the outer sheath 114.

FIG. 12 illustrates a side view of a portion of the distal portion 120of the inner sheath 116 and a portion of the nose shaft 118. In oneimplementation, the distal portion 120 includes the hook 1202, which isadapted to engage body tissue, such as the pericardial sac 108, when thenose shaft 118 is retracted into the inner sheath 116 relative to thedistal edge 220. The helical spiral threads 306 include a cuttingsurface 1204 connected to the hook 1202. In one implementation, the hook1202 is an extension of one of the helical spiral threads 306 and ispartially defined by the cutting surface 1204 defined in the distal edge220 and the helical spiral threads 306. After the hook 1202 engages thebody tissue, the distal portion 120 may be axially rotated causing thecutting surface 1204 to cut through the body tissue. Thus, the hook1202, the helical spiral threads 306, and the cutting surface 1204 canwork together to cause the distal portion 120 of the inner sheath 116 toscrew through body tissue.

As can be understood from FIGS. 13-14, which each illustrate a side viewof an implementation of the device 102 being employed, the device 102may be inserted through body tissue 1302 to pierce the pericardial sac108 to deploy the guidewire 502. As depicted in FIG. 13, after thedistal portion 120 engages the pericardial sac 108, thereby displacingthe indicator 302 and the position marker 802, the inner sheath 116 maybe axially rotated relative to the outer sheath 114 using the middlesheath 212. The indicator 302 and the position marker 802 will remainextended from the outer sheath 114 until the nose shaft 118 and thedistal portion 120 have respectively penetrated through the pericardialsac 108. The indicator 302 and the position marker 802 will thendisplace distally, thereby disappearing from view, as shown in FIG. 14.The distal displacements of the indicator 302 and the position marker802 within the respective confines of the middle sheath 212 and the gripportion 702 identify when the distal tip 218 of the nose shaft 118 ispositioned in the intra-pericardial space 104 and the distal portion 120has threaded through the pericardial sac 108. The guidewire 502 may thenbe routed through the lumen of the nose shaft 118 and into theintra-pericardial space 104, as depicted in FIG. 14.

Various modifications and additions can be made to the exemplaryembodiments discussed without departing from the spirit and scope of thepresently disclosed technology. For example, while the embodimentsdescribed above refer to particular features, the scope of thisdisclosure also includes embodiments having different combinations offeatures and embodiments that do not include all of the describedfeatures. Accordingly, the scope of the presently disclosed technologyis intended to embrace all such alternatives, modifications, andvariations together with all equivalents thereof.

What is claimed is:
 1. A method for controlled penetration into anintra-pericardial space, the method comprising: positioning a distalportion of an inner sheath in close proximity to a pericardial sac, theinner sheath located in an outer sheath; engaging the pericardial sacwith a hook on the distal portion of the inner sheath; and displacingthe inner sheath relative to the outer sheath until an indicator locatedon a proximal portion of a nose shaft displaces distally relative to aproximal end of the a middle sheath coupled to the inner sheath, thedisplacement of the indicator identifying when the nose shaft hasdistally extended from the distal portion of the inner sheath to becomepositioned in the intra-pericardial space.
 2. The method of claim 1,wherein the inner sheath is displaced longitudinally relative to theouter sheath.
 3. The method of claim 1, wherein a distal tip of the noseshaft retracts into the distal portion of the inner sheath when met withresistance from the pericardial sac during the engaging operation. 4.The method of claim 3, wherein the indicator displaces proximallyrelative to the proximal end of the middle sheath when the distal tip ofthe nose shaft retracts.
 5. The method of claim 3, wherein theretraction of the distal tip of the nose shaft exposes the hook on thedistal portion of the inner sheath.
 6. The method of claim 1, whereinthe distal portion of the inner sheath comprises helical spiral threadshaving a cutting surface connected to the hook, the displacing operationcomprising rotating the inner sheath to cut the pericardial sac.
 7. Themethod of claim 1, wherein the indicator includes a colored band.
 8. Themethod of claim 1, further comprising: deploying a guidewire through alumen of the nose shaft into the intra-pericardial space.